Form Cri-300rc - Long Form Renewal Registration Statement

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State of New Jersey
D
L
& P
S
EPARTMENT OF
AW
UBLIC
AFETY
D
C
A
IVISION OF
ONSUMER
FFAIRS
O
C
P
FFICE OF
ONSUMER
ROTECTION
C
R
& I
S
HARITABLE
EGISTRATION
NVESTIGATION
ECTION
124 H
S
, PO B
45021
ALSEY
TREET
OX
N
, NJ 07101
EWARK
(973) 504–6215
Long Form Renewal Registration Statement - CRI-300RC
Confidential Information
Organization Name: _______________________________________________________________
CH _____________________________________
New Jersey Charities Registration Number
1. Are any of the organization’s officers, directors, trustees or five most highly compensated employees related by
blood, marriage or adoption to:
a. each other?
Yes
No
b. any officers, agents, or employees of any fund raising counsel or independent paid fund raiser under contract
to the organization?
Yes
No
c. any chief executive, employee, any other employee of the organization with a direct financial interest in the
transaction, or any partner, proprietor, director, officer, trustee, or to any shareholder of the organization with
more than two (2) percent interest in any supplier or vendor providing goods or services to the organization?
Yes
No
If you answered “YES,” to any of the above, complete question 2.
2. Provide the following information for each of the organization’s officers, directors, trustees, and salaried executive
staff employees: (A list may be attached.)
Name
Title
Home address
Telephone number
Relationship
(Include area code)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
3.
Signature _______________________________________

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